AIM: High-volume facilities provide better CHF care at a higher cost
High-volume hospitals may provide better congestive heart failure care and produce better outcomes than lower volume hospitals, but they do so at a higher price tag, according to a study published in the Jan. 18 issue of the Annals of Internal Medicine.

A larger effort must be made to improve these outcomes and to reform payment systems so that hospitals are incentivized for high quality care, Karen E. Joynt, MD, of the Harvard School of Public Health and Brigham and Women’s Hospital in Boston, told Cardiovascular Business News.

“We were trying to figure out whether experience measured by volume would be related to outcomes for patients with heart failure,” said Joynt. To do so, the researchers used 2006 to 2007 Medicare fee-for-service data that included 1,029,497 Medicare CHF discharges from 4,095 hospitals.

Joynt and colleagues separated hospitals into three groups—low-, medium- and high-volume—and examined process measures such as 30-day risk adjusted-mortality rates, 30-day risk-adjusted readmission rate and costs per discharge.

“Most importantly we found hospitals in the high-volume group had significantly lower 30-day mortality,” said Joynt. The rates of 30-day mortality for low-, medium- and high-volume hospitals were 10.5, 9.3 and 8.5 percent, respectively.

“That 2 percent absolute difference between the low- and high-volume hospitals when you are talking about a million people is a big difference,” Joynt noted.

The mean overall hospital quality alliance score for low-, medium- and high-volume hospitals was 80.2, 87 and 89.1 percent. This measure was based on the following process of care measures: use of ACE inhibitors or ARBs in patients with left ventricular systolic dysfunction, assessment of left ventricular function, discharge instructions and smoking cessation counseling. In all cases, higher volume hospitals fared better.

Joynt said that further research must be done to pinpoint exactly what these higher volume hospitals are doing to gain these favorable outcomes and then share those best practices with lower volume hospitals so they too can improve outcomes.

In addition to these processes of care measurements, the researchers reported the costs per patient discharge. Joynt et al found that high-volume hospitals spent almost $1,200 more per patient when compared to low-volume hospitals, $8,382 versus $7,189.

“In the health reform debate, everyone is trying to find a system where we can achieve better outcomes at a lower cost. Some people argue that there are lots of places where we will be able to both improve care and decrease costs simultaneously, but that solution has yet to be found," she said.

However, it is important to first understand why the higher volume hospitals are spending more money per discharge. "Is it that they are performing more procedures?" she asked.

While the higher volume hospitals are spending almost $1,200 more upfront, they are reducing mortality and readmission rates, "so maybe it’s worth it," she said.

“Although they have higher upfront costs, we need to understand a cost-benefit analysis of how this plays out because right now high-volume hospitals are paid no differently than low-volume hospitals,” Joynt noted.

Currently, higher volume hospitals are receiving the same amount of money from Medicare as lower volume hospitals, and there is nothing in the current payment system that pays hospitals for quality. An evaluation of the payment system is necessary. “Bundled payments or pay-for-performance payment systems would incentivize hospitals that are performing better, and those who reduce readmissions and keep patients alive, healthy and out of the hospitals."

Joynt said that the rates of hospital readmission within 30 days of hospital discharge are 25 percent, and too high. She said that providing better education to the patient about medications, diet and condition at discharge could help to decrease these rates.

“We know that putting resources in by nurses and nutritionists can help heart failure patients, but those are costly and they are not available or realistic for everyone,” she concluded.